UWorld Flashcards
(297 cards)
1
Q
SERMs are a class on nonsteroidal compounds that exhibit estrogen agonist and antagonist properties in a tissue-specific fashion. The 2 most frequently used SERMs are raloxifene and tamoxifen. Raloxifene exhibits estrogen agonist activity on the bone and decreases post-menopausal osteoporosis. Although less effective than aldendronate, raloxifene is frequently used for osteoporosis management in postmenopausal women who cannot tolerate bisphosphonates or are at high risk for invasive breast cancer. All medicines with estrogen agonist activity increase risk for what
A
VTE
2
Q
Shoulder dystocia frequently occurs in patients with no risk factors and can be difficult to predict. What are the warning signs of an impending dystocia
A
- Prolonged first or second stage of labor
- retraction of the fetal head into the perineum after delivery (turtle sign)
3
Q
ilateral inguinal lymphadenopathy and a painless genital chancre
A
Classic symptoms of primary syphilis
4
Q
Describe the lesion of primary syphilis
A
-single papule that turns into a shallow, painless, NONexudative ulcer with indurated edges
5
Q
initial RPR result in early primary syphilis
A
Can be negative
6
Q
Patients with negative screening serology and strong clinical evidence of primary syphilis should be treated how
A
impirically with Intramuscular benzathine penicillin G
-repeat nontreponemal serology should be done in 2-4 weeks to establish baseline titers
7
Q
Clinical presentation of epithelial ovarian carcinoma?
A
- Acute: shortness of breath, obstipation/constipation with vomiting, abdominal distention
- Subacute: pelvic abdominal pain, bloating, early satiety
- Asymptomatic adnexal mass
8
Q
US findings in epithelial ovarian carcinoma?
A
- Solid mass
- Thick septations
- Ascites
9
Q
Management of epithelial ovarian carcinoma
A
-Exploratory Laparotomy
10
Q
Ascites from epithelial ovarian carcinoma is likely due to what
A
-peritoneal spread of cancer causing increased capillary permeability and decreased intravascular oncotic pressure
11
Q
What is the use of CA-125 in epithelial ovarian carcinoma
A
-to correlate with clinical finding and to monitor treatment in the future
12
Q
In an RH- woman in second pregnancy having RH+ baby will need anti-D immune globulin. A standard dose of 300 ug at 28 weeks gestation can usually prevent alloimmunization. However, about 50% of Rh-negative women will need a higher dose after delivery, placental abruption, or procedures. What is commonly used to determine the dose
A
KB test
13
Q
Antenatally diagnosed placenta accreta is delivered how
A
planned Cesarean hysterectomy
14
Q
Risk factors for placenta accreta
A
- prior C section
- History of D and C
- Advanced maternal age
15
Q
correlation of OCPs and HTN
A
- OCPs can cause mild elevations in BP and sometimes lead to overt HTN.
- Discontinuing OCPs can reduce the BP over a 2 t o12 month period and can often correct the problem
16
Q
Depot Medroxyprogesterone acetate (DMPA) is administered IM how often to prevent pregnancy by inhibiting the release of GRH from the hypothalamus and suppressing ovulation
A
every 3 months
17
Q
Treatment of confirmed Chlamydia but Negative Gonorrhea? . . . If using NAAT
A
Just Azithromycin
-If culture or microscopy used then always treat both
18
Q
Treatment of confirmed Gonorrhea but negative chlamydia? . . . If using NAAT
A
BOTH Azithromycin and ceftriaxone
19
Q
Fat necrosis is a benign condition associated with what
A
-breast surgery and trauma
20
Q
Fat necrosis can mimic breast cancer in its clinical and radiographic presentation because it commonly presents as what?
A
-a fixed mass with skin or nipple retraction and gives the appearance of calcifications on mammography
21
Q
Biopsy is diagnostic of fat necrosis and typically shows what
A
Fat globules and foamy histiocytes
22
Q
once fat necrosis is diagnosed, what is the most appropriate course of action in management
A
Reassurance and routine follow up
23
Q
Complications of inadequate pregnancy weight on the fetus
A
- Fetal growth restriction
- Preterm delivery
24
Q
- unilateral bloody nipple discharge
- No associated mass or lymphadenopathy
A
Intraductal papilloma
25
Management of intraductal papilloma
- Mammography and US
| - Biopsy +/- excision
26
- Patient with abortion history presents at 35 weeks with decreased fetal movement and placenta previa
- NST done and fetus has heart tones at 130 but no accels (nonreactive)
- NExt step?
BPP or Contraction stress test (CST)
| -CST is contraindicated in placenta previa or prior myomectomy
27
Normal Nonstress test finding in BPP?
Reactive fetal heart rate monitoring
28
Normal Amniotic fluid volume finding in BPP
- Single fluid pocket > 2x1 cm
| - or amniotic fluid index >5
29
Normal fetal movement finding in BPP
-3 or more general body movements
30
Normal fetal tone finding in BPP
1 or more episodes of flexion/extension of fetal limbs or spine
31
Normal fetal breathing movements finding in BPP
1 or more breathing episode for at least 30 sec
32
An abnormal BPP score of 0/10 to 4/10 indicates what?
fetal hypoxia due to placental dysfunction
| -Prompt delivery is indicated due to the high probability of fetal demise
33
Normal ovulation can cause pain in the middle of the menstrual cycle called what ?
What is the pathophys of the pain?
Mettelschmerz
-Rupture of the follicle releases the egg. The concomitant release of a small amount of blood during this process irritates the peritoneum
34
Advice regarding alcohol to patients getting treated for trich
refrain from alcohol consumption after treatment due to risk of a disulfiram-like reaction
35
Chorionic villus sampling is a diagnostic genetic test performed at what weeks?
-10-13
36
Amniocentesis is a diagnostic genetic test performed at what weeks
15-20
37
This results from incomplete regression of the Wolffian duct during fetal development. These cysts may be single or multiple and are submucosal along the lateral (parallel) aspects of the upper anterior vagina
Gartner duct cyst
38
management of an asymptomatic Bartholin cyst in a young woman
- no intervention
| - Observation is recommended as spontaneous drainage and resolution may occur
39
management of symptomatic Bartholin cyst
- I and D
| - Placement of a word catheter after drainage reduces the risk of recurrence
40
US differentiates ovarian torsion from other acute gynecologic conditions by the presence of what?
- adnexal mass
| - lack of Doppler flow . . .pathognomonic finding
41
next step in management of ovarian torsion
surgery . laparoscopic cystectomy and detorsion
42
A patient with gestational HTN needs BPPs how often and starting when
- every week
| - starting at 32 weeks
43
Patient comes in at 37 weeks with severe preeclampsia and delivers. What complications can newborn have
- pathophys likely involves abnormal placental development and function, which puts the fetus at risk for chronic uteroplacental insufficiency
- This can leads to fetal growth restriction/low birth weight even if the neonate is delivered at term
44
Describe the pathophysiology of HELLP syndrome
- thought to result from abnormal placentation, triggering systemic inflammation and activation of the coagulation system and complement cascade
- circulating platelets are rapidly consumed, and microangiopathic hemolytic anemia is particularly detrimental to the liver
- The resulting hepatocellular necrosis and thrombi in the portal system cause elevated liver enzymes, liver swelling, and distension of the hepatic (Glisson) capsule
45
Treatment of HELLP
- Delivery
- Mag for seizure prophylaxis
- Antihypertensive drugs
46
Adolescent Pts with an imperforate hymen typically present with what
- cyclic lower abdominal pain in the absence of apparent vaginal bleeding
- When menstruation occurs, blood collects in the vagina behind the hymenal membrane (hemocolpos)
- The enlarging blood collection with each menstrual period causes increasing pressure on the surrounding pelvic organs, resulting in lower back pain, pelvic pressure, or defactory rectal pain
47
The strongest risk factor for preterm delivery is preterm delivery. What are other important risk factos
- Multiple gestation
- Hx of cervical surgery. In particular, removal of part of the cervix by cold knife conization for cervical intraepithelial neoplasia can cause cervical scarring/stenosis and incompetence
48
What is the first step in evaluating the risk of preterm delivery?
-Transvaginal US measurement of cervical length in the second trimester
49
When are Fetal fibronectin levels normally high and when can they be used as an indicator for increased risk of preterm delivery?
- FFN levels are high until 20 weeks
- Low during the mid-second and third trimesters and increase again at term when contraction disrupt the decidual-chorionic interface
- Elevated levels prior to term but after 20 weeks can indicate risk of preterm
50
If evaluated by transvaginal US and determined to have a short cervic then what can be given?
- Progesterone maintains uterine quiescence and protects the amniotic membranes against premature rupture
- Pts with short cervices and NO Hx of preterm delivery should be offered VAGINAL progesterone
- Pts with a Hx of preterm delivery receive IM progesterone
51
Hyperandrogenism during pregnancy is usually caused by ovarian masses. A luteoma is a benign condition that occurs more frequently in African American. Describe presentation and management
- hirsutism and acne
- US shows large solid ovarian masses and half are bilateral
- Management involves clinical monitoring and US evaluation as the mass and symptoms regress spontaneously after delivery
52
Patients with Luteomas in pregnancy have increased risk of what?
puts a female fetus at high risk of virilization
53
What is the first line therapy for ovulation induction in PCOS
Clomiphene
54
electrolyte abnormality that can be caused by oxytocin
Hyponatremia
55
Seizures and Oxytocin?
- patient with new onset generalized tonic clonic seizure in setting of severe hyponatremia.
- Seizure probably due to water intoxication from excessive oxytocin administration during the postpartum hemorrhage after a prolonged induction of labor
- similar in structure to ADH
- Management involves gradual administration of hypertonic saline
56
Therapeutic Magnesium range
5 to 8
57
A tender, mobile breast mass in a young patient is most likely benign. In a patient < 30 with a clinically benign mass, breast US is the first line imaging study. if consistent with simple breast cyst what would be the management?
- aspiration, which should yield clear fluid and result in disappearance of the mass and thereby confirm Dx
- As cystic fluid can reaccumulate, the patient should return in 2-4 months for a follow up clinical breast exam
58
What are the symptoms and Physical exam findings of gentiourinary syndrome of menopause?
- Vulvovaginal dryness, irritation, pruritus
- Dyspareunia
- Vaginal bleeding
- Urinary incontinence, recurrent UTI
- pelvic pressure
- Narrowed introitus
- Pale mucosa, low elasticity, low rugae
- petechiae, fissures
- Loss of labial volume
59
Treatment of genitourinary syndrome of menopause
- Vaginal moisturizer and lubricant
| - Topical vaginal estrogen
60
The diagnosis of intrauterine fetal demise must be confirmed by what
absence of fetal cardiac activity on US
61
Describe the evaluation after fetal demise
Fetal: Autopsy, Gross and microscopic exam of placenta, membranes and cord, Karyotype/genetic studies
Maternal: KB test for fetomaternal hemorrhage, antiphospholipid antibodies, coagulation studies
62
Describe Lactational amenorrhea
- result of high levels of prolactin, which has an inhibitory effect on the production of GnRH
- natural form of contraception for the first 6 months postpartum if the mother is breastfeeding exclusively
63
risk factors for ovarian torsion
- ovulation induction (infertility treatment)
| - preexisting ovarian masses, especially those that are large
64
Management of ectopic pregnancy?
- stable: methotrexate
| - Unstable or ruptured: surgery
65
The presence of fluid in the posterior cul-de-sac in the setting of an ectopic pregnancy suggests what
blood in the pelvis
66
pregnant patient with postcoital bleeding and a thick, mucopurulent discharge and friable cervix
acute cervicitis
67
Describe the presentation of an inevitable abortion
- Vaginal bleeding
- cramping
- dilated cervix
- often with products of conception visualized at the os
68
Small genital warts (condyloma acuminata) may be treated how?
- Trichloracetic acid or podophylin resin
| - excisional therapy may be considered for larger lesions
69
On pap smear, High-grade squamous intraepithelial lesions (HSILs) on pap testing are concerning for underlying severe neoplasia or invasive cervical cancer , and all patient require what
evaluation with immediate colposcopy
-Can be treated with immediate loop electrosurgical excision but pregnant patients first undergo colposcopy and then cervical excision only if evidence of invasive cancer is found
70
if HSIL found on pap and then on colposcopy the transformation zone of SC junction are not visualized then what?
- endocervical curettage to evaluate endocervical canal
| - This is deferred during pregnancy due to risk of miscarriage and preterm delivery
71
An athletic patient with secondary amenorrhea, a negative pregnancy test, and normal prolactin and TSH levels has a clinical pictures consistent with what diagnosis?
Functional hypothalamic amenorrhea
72
What can confirm functional hypothalamic amenorrhea
- A progestin challenge test confirms low estrogen levels
- The presence of estrogen causes proliferation of the endometrium, with subsequent sloughing after the withdrawal of progesterone
- Patients without adequate estrogen will have no or minimal bleeding as there is no endometrial lining to shed
73
Functional hypothalamic amenorrhea and bone density?
-Will have decreased bone mineral density despite physical training due to the low estrogen levels offsetting the bone-building effects of exercise
74
In functional hypothalamic amenorrhea, what can offset and increase bone density
- Estrogen repletion
| - Increasing caloric intake and/or decreasing exercise is a more effective means
75
What is the most common cause of prolonged or arrested second stage of labor
fetal malposition
76
What is the optimal fetal position
-Occiput anterior
77
What is the most common cause of a protracted first stage of labor
inadequate contractions (,3 in 10 minutes, soft to palpation)
78
In genitourinary syndrome of menopause, the diagnosis can be made clinically, but laboratory testing such as what confirms the hypoestrogenic state
-elevated vaginal pH >5
79
Next step in a patient who has arrest of active labor as she has had no cervical change in 4 hours despite adequate contractions
C section
80
What are the Fetal Late-term and postterm pregnancy complications
- Oligohydramnios
- Meconium aspiration
- Stillbirth
- macrosomia
- convulsions
81
What are the Maternal Late-term and postterm pregnancy complications
- C section
- infection
- postpartum hemorrhage
- Perineal trauma
82
US showing a thin endometrial stripe suggests what
an empty and normal uterine cavity
83
First line treatments for Asymptomatic bacteriuria?
- Cephalexin
- Amoxicilli-clavulanate
- Nitrofurantioin
- Fosfomycin
84
Describe the use of Trimethoprim-Sulfamethoxazole during pregnancy?
- Safe during second trimester
- contraindicated during the first trimester due to interference with folic acid metabolism
- Should be avoided during the third trimester due to increased risk of neonatal kernicterus
85
most effective emergency contraceptive
copper IUD
86
Postpartum endometritis typically presents with fever >24 hours postpartum and what else
- purulent lochia
| - uterine tenderness
87
What is calcium gluconate used for
- used for calcium repletion in patients with hypocalcemia
| - it is also an antidote for magnesium toxicity
88
Adolescents often have anovulatory cycles with irregular, heavy menstrual bleeding due to an immature hypothalamic-pituitary axis. How can this be managed
Progesterone normalizes mentruation by stabilizing unregulated endometrial proliferation
89
How does Pelvic inflammatory disease typically present
- fever
- lower abdominal tenderness
- mucopurulent cervical discharge
- cervical motion and uterine tenderness
- Intermenstrual spotting can occur
- Infection can extend from the upper genital tract to spread throughout the abdomen and cause liver capsule inflammation (e.g. perihepatitis or Fitz-Hugh-Curtis disease) . . RUQ pain
90
Most appropriate management advice for a patient with fetal demise at 28 weeks gestation
Labor can be induced in the hospital when you feel ready
91
What time frame is Dilation and evacuation indicated for intrauterine fetal demise
<24 weeks
92
Adnexal mass or fullness should be confirmed by US, and the finding of a homogeneous cystic ovarian mass is highly suggestive of what
an ovarian endometrioma
93
what is a common consequence of endometriosis, especially with the presence of endometrioma
infertility
94
Type of abortion: -No vaginal bleeding
- closed cervical os
- No fetal cardiac activity or empty sac
Missed abortion
95
Type of abortion: -vaginal bleeding
- Closed cervical os
- Fetal cardiac activity
Threatened
96
Type of abortion: -Vaginal bleeding
- Dilated cervical os
- Products of conception may be seen or fest at or above cervical os
Inevitable
97
Type of abortion: Vaginal bleeding
- Dilated cervical os
- Some products of conception expelled and some remain
-Incomplete
98
Type of abortion: -vaginal bleeding
- close cervical os
- Products of conception completely expelled
complete abortion
99
this presents with painless vaginal bleeding and fetal heart rate abnormalities after amniotomy
-vasa previa
100
Palpable breast mass. what imaging is indicated next in women >30?
How about <30?
what confirms diagnosis?
- Mammography and targeted US can further characterize
- US is preferred for women <30, although mammography can be used for further characterization if an abnormality is seen
- Tissue biopsy is required to confirm
101
Clinical features of hyperemesis gravidarum
- Severe, persistent vomiting
- >5% loss of prepregnancy weight
- dehydration
- Orthostatic hypotension
102
Hyperemesis gravidarum can be differentiated from typical nausea and vomiting of pregnancy by the presence of what
- ketones on UA
- lab abnormalities
- changes in volume status
103
Treatment and management of chorioamnioitis
- broad spectrum IV antibiotics (Amp, Gent, Clinda)
| - Immediate delivery via INduction of labor
104
What are the indications for hospitalization for PID
- Pregnancy
- Failed outpatient treatment
- Inability to tolerate oral meds
- Noncompliant with therapy
- Severe presentation (e.g. high fever, vomiting)
- Complications (e.g. tubo-ovarian abscess, perihepatitis)
- Recommended for adolescents due to the risk of noncompliance
105
Antibiotic regimen for hospitalized PID patients
- IV cefoxitin or cefotetan plus
- oral doxycycline .
-or can use IV clinda plus gent
106
When is metronidazole added to PID treatment
when it's complicated by tubo-ovarian abscess due to required additional anaerobic coverage
107
What is the pathophysiology of neonatal thyrotoxicosis
- Transplacental passage of maternal anti-TSH receptor antibodies
- Antibodies bind to infant's TSH receptors and cause excessive thyroid hormone release
108
Treatment of Neonatal thyrotoxicosis
- Self-resolves within 3 months (disappearance of maternal antibody)
- Methimazole PLUS Beta blocker
109
Daughters of women who used diethylstilbestrol are at increased risk for developing what kind of cancer
- clear cell adenocarcinoma of the vagina and cervix
| - Many of these women have cervical or uterine malformations as well as difficulty conceiving and maintaining pregnancy
110
Clinical features of vulvar lichen sclerosus
- Thin, white, wrinkled skin over the labia majora/minor; atrophic changes that may extend over the perineum and around the anus
- Excoriations, erosions, fissures from severe pruritus
- Dysuria, dyspareunia, painful defacation
111
Workup of vulvar lichen slerosus
-punch biopsy of adult-onset lesions to exclude malignancy
112
treatment of vulvar lichen sclerosus
superpotent corticosteroid ointment
113
Hypotension is a possible side effect of epidural anesthesia. If persistent and untreated it can result in decreased placental perfusion and can lead to fetal acidosis. What is the pathophysiology of the hypotension?
-sympathetic nerve fibers responsible for vascular tone are blocked, resulting in vasodilation (venous pooling), decreased venous return to the right side of the heart, and decreased cardiac output
114
Hypotension is a possible side effect of epidural anesthesia. If persistent and untreated it can result in decreased placental perfusion and can lead to fetal acidosis. How can it be prevented?
-aggressive IV fluid volume expansion prior to epidural placement
115
Hypotension is a possible side effect of epidural anesthesia. If persistent and untreated it can result in decreased placental perfusion and can lead to fetal acidosis. How can it be treated?
- Left uterine displacement (Positioning patient on the left side) to improve venous return
- Additional IV fluid bolus
- Vasopressor administration
116
Depression of cervical spinal cord and brainstem activity occurs when local anesthesia ascends toward the head, also known as a "high spinal" or "total spinal", a dangerous complication of epidural anesthesia. It may happen with intrathecal injection or overdose of the anesthesia. What are the signs?
- First signs: Hypotension, bradycardia, and respiratory difficulty
- Later: diaphragmatic paralysis and possibly cardiopulmonary arrest
117
Leakage of cerebral spinal fluid may occur if the dura is inadvertently punctured during epidural placement. This results in leakage of spinal fluid and is known as a "wet tap". Patients may experience what symptoms
-postural headaches that are worse with sitting up and improved with lying down after delivery
118
Does cervical laser ablation increase the risk of preterm delivery
No
119
Management of PPROM at 34-37 weeks with inknowne GBS status
- antibiotics
| - deliver
120
What is amnioinfusion used for
-for treatment of recurrent variable decels due to umbilical cord compression during labor
121
Bilateral, gray, nonbloody nipple discharge, guaiac negative is consistent with what ?
-Initial evaluation?
physiologic galactorrhea
| -should focus on identifying etiology and includes serum prolactin, THS, and pregnancy test
122
what is measured in conjunction with pelvic US finding to categorize ovarian mass as likely malignant or benign
CA-125 levels
123
In a postmenopausal patient, an elevated CA-125 level in the context of an adnexal mass is highly suspicious for what
malignancy
124
Endometrial biopsy is performed to investigate for endometrial carcinoma and is indicated in patients with what symptoms
- postmenopasual bleeding
- abnormal uterine bleeding over age 45
- or thickened endometrial stripe with an ovarian mass
125
Why is needle aspiration contraindicated in postmenopausal women with an adnexal mass
risk of spreading potentially malignant cells should the mass prove to be cancerous
126
- Sudden-onset, severe unilateral lower abdominal pain immediately following strenuous or sexual activity
- Pelvic free fluid
-Ruptures ovarian cyst
127
Elevated maternal serum alpha-fetoprotein in pregnancy is associated with what defects?
- Open neural tube defects (e.g. anencephaly, open spina bifida)
- Ventral wall defects (e.g. omphalocele, gastroschisis)
- multiple gestation
128
Decreased Maternal serum alpha-fetoprotein in pregnancy is associated with what
-Aneuploidies (e.g. trisomy 18 and 21)
129
Elevated maternal serum alpha-fetoprotein in pregnancy warrants what further test
careful US evaluation of the fetal anatomy
- in addition, number of fetuses should be clarified
- Gestational age is also confirmed as interpretation of AFP level depends on an accurate gestational age
130
What is recommended to all women who are in labor with active genital HSV lesions or prodromal symptoms
C section
131
Pregnancy women with a history of genital HSV infection should receive prophylactic acyclovir or valacyclovir beginning when
36 weeks
132
When is testing for toxoplasmosis indicated
only when patients have symptoms of potential infection (e.g. fever, malaise, lymphadenopathy)
133
Describe the maternal management of Hepatitis C infection in pregnancy?
- Ribavirin is TERATOGENIC and should be avoided
- No indication for barrier protection in serodiscordant, monogamous couples
- Hepatitis A and B vaccination
134
Is C section protective of vertical transmission of Hep C
No
135
Hep C and breast feeding
- Breastfeeding does NOT increase the risk of HCV transmission to the neonate
- Should be suspended only if the nipple area is actively bleeding
136
Scraping of a vulvar lesion for potassium hydroxide testing is performed when dermal candidiasis is suspected. How does vulvar yeast present
as red and flaky patches with satellite lesions and possible extension to the inner thighs and groin
137
What is the ultrapotent topical corticosteroid ointment that is the first line treatment for relief of itching and other symptoms of lichen sclerosus
Clobetasol
138
What is the most important direct role of hCG in pregnancy
- Secreted by the syncytiotrophoblast and is responsible for Maintenance of the corpus luteum during early pregnancy in order to maintain progesterone secretion until the placenta is able to produce progesterone on its own
139
role of progesterone in pregnancy
inhibits uterine contractions
140
what hormone is responsible for preparing the endometrium for implantation of a fertilized ovum
progesterone
141
The diagnosis of ectopic pregnancy is made by a pregnancy test combined with what?
- TransVAGINAL US
| - Transabdominal US cannot reliably visualize a gestational sac super early in pregnancy
142
Mother has blood group O and a husband with blood group AB . . they will have a child with either blood group A or B. In these situations of ABO incompatibility, describe the risk of hemolysis?
- Signs of hemolytic disease are typically mild and apparent only in about 1/3 of infants
- Affected infants are usually asymptomatic or mildly anemia at birth
- Within the first 24 hours of life they may develop jaundice (e.g. hyperbilirubinemia), which typically resons to phototherapy
143
Can ABO incompatibility affect first pregnancy?
yes because patients with blood group O are exposed to A and B antigens early in life (from exposure to A- and B- like antigens present in food, bacteria, and viruses) and produce IgG
144
Presentation of Theca Lutein cysts
- Multilocular
- Bilateral
- 10-15 cm ovaries
145
Pathogenesis of theca lutein cysts
- Ovarian hyperstimulation due to:
- Gestational trophoblastic disease
- Multifetal gestation
- Infertility treatment
146
Clinical course of theca lutein cysts?
-Resolve with decrasing beta-hCG levels
147
Hyperemesis gravidarum, an enlarged uterus, and bilarerally enlarged ovaries is a presentation concerning for what
hydatidiform mole
148
Pathogenesis of theca lutein cysts from hydatidiform mole
ovarian hyperstimulation from abnormal trophoblastic proliferation
149
Target blood glucose levels in Gestational DM
- Fasting <95
- 1 hour postprandial: <140
- 2 hour postprandial <120
150
Atypical glandular cells on Pap testing may be due to what/
either cervical or endometrial adenocarcinoma
151
Atypical glandular cells on Pap testing is further investigated how?
- Colposcopy
- endocervical curettage
- endometrial biopsy
152
baby with klumpke palsy and horner syndrome after shoulder dystocia and forceps delivery. What nerves affected
-C8 and T1
153
Erb-Duchenne palsy involves what nerves
C5 and C6
154
Describe the course of genital herpes if untreated
Resolution then DECREASINGLY frequent recurrences
155
Rectovaginal fistula presents with incontinence of flatus or fecal material through the vagina, causing a malodorous brown/tan discharge. Diagnosis is usually confirmed by visual examination showing what?
-Dark red, velvety rectal mucosa on the posterior vaginal wall
156
Risk factors for pubic symphysis diastasis
- Fetal macrosomia
- Multiparity
- Precipitous labor
- Operative vaginal delivery
157
Presentation of Pubic symphysis diastasis
- Difficulty ambulating
- Radiating suprapubic pain
- Pubic symphysis tenderness
- Intact neurologic exam
158
Femoral nerve damage can occur during delivery as a result of hyperflexion of the thigh (McRoberts Maneuver). How does it present
- numbness over the anterior and medial thigh
- inability to extend the leg or flex the thigh
- diminished patellar reflexes
159
Patient with Amniotomy at +1 station at 7 cm dilation went from intermittent variable decels to recurrent. What would first line intervention be
- Maternal repositioning (Left lateral) which may reduce cord compression and improve blood flow to the placenta
- Should these fail, amnioinfusion is a reasonable second-line intrauterine resuscitation option
- If fully dilated then instrumental vaginal delivery would be indicated
160
Unilateral bloddy nipple discharge is the hallmark of what? . . no associated mass or lymphadenopathy
-intraductal papilloma
161
management of breast abscess
- Needle aspiration under US guidance and antibiotics (Dicloxacillin, cephalexin)
- Incision and drainage with packing are recommended for abscesses not responsive to needle aspiration and antibiotics, suspected necrotic material, and Large (>5cm) pus collections
162
- Male karyotype
- male testosterone levels
- Breast development
- Primary amenorrhea (absent ovaries, uterus, cervix)
- Minimal pubic and axillary hair
Androgen insensitivity syndrome
| -mutated androgen receptor
163
This occurs in 46,XX females and consists of no upper vagina, cervix, or uterus, but otherwis normal femal development
-Should have normal pubic and axillary hair and female testosterone levels
Mullerian agenesis (Mayer-Rokitansky-Kuster-Hauser syndrome)
164
This occurs close to ovulation (late follicular phase) and can be perceived by patients as vaginal discharge. The mucus is clear, elastic, thin in consistency and described similar in appearance to an uncooked egg white
Cervical mucus
165
A palpable, well-circumscribed, mobile breast mass in women age <30 suggest what
a benign process, most commonly a fibroadenoma
166
This presents as multiple, small, cyclically tender masses (diffuse breast nodularity) on physical examination
Fibrocystic breast changes
167
Clinical presentation of a septic abortion
- Fever, chills, abdominal pain
- Sanguinopurulent vaginal discharge
- Boggy, tender uterus; dilated cervix
- Pelvic US: retained POC, thick endometrial stripe
168
Management of a septic abortion
- IV fluids
- Broad spectrum antibiotics
- Suction currettage
169
Patient at 35 weeks gestation with irregular contractions and a closed cervix is consistent with what
False labor
170
When does tocolysis for preterm labor become contraindicated
34 weeks
171
management of patient in false labor
- can resume routine prenatal care
| - reassure patient and discharge home
172
Patient presents with amenorrhea, breast fullness, morning sickness, and abdominal distension - symptoms of early pregnancy - and believes she is pregnant. However, her office exam (thin endometrial stripe, negative urine pregnancy) excludes pregnancy. This is consistent with what
Pseudocyesis
173
risk factors for pseudocyesis
- Hx of infertility
| - Prior pregnancy loss
174
Management of inevitable abortion
- Expectant or medial (e.g. misoprostol) management is appropriate in hemodynamically stable patients with minimal bleeding
- Surgical (suction currettage) indicated for hemodynamically unstable patients
175
At what Beta-hCG level is fetus usually visible by transvaginal US
1500
| -If the level is <1500 then repeat in 2 days
176
Anti-D immune globulin is indicated when
in unsensitezed, Rh-negative women at 28 weeks gestation or within 72 hours of any procedure or incident in which there is any possibility of feto-meternal blood mixing
177
What is considered a nonreactive (abnormal) NST
,2 accelerations in 20 minutes
178
Most common cause of a nonreactive NST and what should be done?
- Fetal sleep cycle
| - Vibroacoustic stimulation to awaken fetus and allow timely test
179
Patient presents with menstrual irregularities (e.g. anovulation), infertility, and enlarged ovaries. In addition, the presence of acanthosis nicricans indicates insulin resistance. These are clinical manifestations of what?
polycystic ovarian syndrome
180
describe management of PCOS in patient wanting to get pregnant
- Weight loss to reestablish ovulation by decreasing the peripheral estrogen conversion
- if unsuccessful then clomiphene citrate, a selective estrogen modulator that primarily blocks estrogen receptors at the levels of the hypothalamus and inhibits the negative feedback
181
Breast cancer and Combined hormonal contraceptives?
ABSOLUTE CONTRAINDICATION . . . actually all hormonal containing contraception would be so copper IUD would be best
182
What 2 uterine surgeries makes a trial of labor contraindicated
- Classical C section (Vertical incision)
| - Abdominal myomectomy with uterine cavity entry
183
Patient with previous myomectomy, intense constant abdominal pain, and persistent variable decelerations are concerning for what
uterine rupture . . . so urgent laparotomy and delivery
184
Amnioinfusion and Hx of uterine surgery
contraindicated
185
Blunt abdominal trauma is a significant risk factor for severe hemorrhage from placenta abruption. Initial management involves what?
-Aggressive fluid resuscitation and uterine displacement to optimize maternal circulation
186
Engorgement results when milk production exceeds release, and this patient has engorged breasts due to rapid cessation of breastfeeding. How is lactation suppression accomplished?
- by wearing a comfortable, supportive bra
- avoidance of nipple stimulation and manipulation
- application of ice packs to the breasts
- NSAIDs
187
- Heavy menses
- Constipation, urinary frequency, pelvic pain/heaviness
- enlarged uterus
Fibroids
188
- Dysmenorrhea, pelvic pain
- Heavy menses
- Bulky, globular, and tender uterus
Adenomyosis
189
- History of obesity, nulliparity, or chronic anovulation
- Irregular, intermenstrual, or postmenopausal bleeding
- Nontender uterus
Endometrial cancer/hyperplasia
190
How does obesity cause endometrial hyperplasia
-increases circulating estrogen levels through increased peripheral conversion of androgens to estrogens and aromatization of androstenedione to estrone
191
Hallmarks of endometriosis . . . "the 3 D's"
- Dysmenorrhea
- DEEP dyspareunia
- dyschezia (pain with defacation)
- Other features include pelvic pain and infertility
192
What are the first line empiric treatment for endometriosis without definitive surgical diagnosis, such as in this patient without plans for immediate conception
-NSAIDs and or combined oral contraceptives
193
Primary infertility is defined as failure to conceive after a year of unprotected, times sexual intercourse in a nulliparous patient age <35 (after age 35, infertility investigation can begin after 6 months). If patient has history of PID what would be next step
-Hysterosalpingogram to assess fallopian tube patency
194
A woman has a 1 in 8 lifetime risk of breast cancer. What is a dose dependent risk factor and reduced intake will decrease the risk of breast cancer?
- Alcohol consumption
| - Protective lifestyle aspects include exercise and breastfeeding
195
In obstetrical ethical decisions who has the ultimate rights?
The mother is considered to have ultimate rights over her unborn child, assuming she has capacity
196
Violent muscle contractions, as seen in a seizure or electrocution injury (maybe eclampsia), are a common cause of what shoulder pathology
posterior shoulder dislocation
197
Describe the shoulder in a posterior shoulder dislocation
-The shoulder is typically held in adduction and internal rotation, with visible flattening of the anterior aspect of the shoulder and prominence of the caracoid process
198
IN anterior shoulder dislocations, the patient holds the arm how
slightly abducted and externally rotated
199
Describe Todd paralysis
transient unilateral weakness following a tonic clonic seizure that usually spontaneously resolves
200
Wernicke encephalopathy is a neurological disease due to a thiamine deficiency. Although most commonly associated with alcoholsim, it can occurs with what disorder associated with pregnancy?
Hyperemesis gravidarum, a severe, persistent nausea and comiting of pregnancy that results in weight loss and dehydration
201
Lab values associated with hyperemesis gravidarum
- Hypochloremic metabolic alkalosis
- hypokalemia
- hypoglycemia
- elevated serum aminotransferases
- All of these are the result of protracted vomiting
202
treatment of asymptomatic endometriosis found incidentally during a different surgery
just observation
203
What is the only current indication for hormonal replacement therapy
-vasomotor symptoms in women <60 who have undergone menopause within the past 10 years
204
Describe advice to pregnant patients on lithium
-In patients who have stable bipolar disease, slow tapering of lithium should be considered
205
Active labor and external cephalic version
relative contraindication
206
Hx of recurrent pregnancy loss and prior transient eschemic attack is concerning for what?
- Thrombophilia
- Antiphospholipid syndrome is an autoimmune disorder that presents with pregnancy complication or venous or arterial thrombis
207
What should be the first diagnostic test used to confirm the diagnosis of appendicitis in pregnancy and can also be helpful to rule oute other potential diagnoses?
US
208
Universal screening for GBS in pregnancy
rectovaginal culture at 35-37 weeks gestation
209
Women who miss screening for GBS (status unknown) should be treated in labor under what circumstances?
- ,37 weeks gestation
- Develop intrapartum fever
- have ROM for >18 hours
210
Typical presentation is dysmenorrhea with heavy menstrual bleeding (soaking a pad or tampon more often than every 2 hours) that starts later in reproductive years with progression to chronic pelvic pain.
Classic physical exam findings are a boggy tender, uniformly enlarged uterus
Adenomyosis
211
Lab abnormalities in intrahepatic cholestasis of pregnancy
- Elevated bile acids
| - Elevated levels of liver enzymes
212
Red papules within striae with sparing around the umbilicus sometimes extending to the extremities
PUPPP
213
Adverse effects of SERMs (Tamoxifen and Raloxifene)
- Hot flashes
- VTE
- Endometrial hyperplasia and carcinoma (Tamoxifen only)
214
Lack of menses is considered normal until what age if development of secondary sex characteristics has been appropriate?
-15
215
In PCOS, what is the mechanism behind anovulation or infertility
failure of follicle maturation
216
The initial menstrual cycles in adolescents are irregular and anovulatory due to what?
hypothalamic-pituitary-gonadal axis immaturity and insufficient secretion of gonadotropin-releasing hormone
217
Secondary Amenorrhea is absence of menses for 6 months. If Beta-hCG is negative and the is no prior uterine procedure or infection then what is the further workup
- Prolactin
- TSH
- FSH
218
What should be considered in a patient with no history of skin disease who develops a breast rash?
Breast cancer . . most commonly adenocarcinoma
219
Sudden onset of abdominal pain, recession of the presenting part during active labor, and fetal heart rate abnormalities are red flags for what?
-uterine rupture
220
Clinical presentation of amniotic fluid embolism
- Cardiogenic shock
- Hypoxemic respiratory failure
- DIC
- Coma or seizures
221
Treatment of amniotic fluid embolism
-Respiratory and hemodynamic support
222
This is a form of gestational trophoblstic neoplasia, a malignancy that arises from placental trophoblastic tissue and secretes Beta-hCG
choriocarcinoma
223
Choriocarcinoma typically presents when
< 6 months after a pregnancy
224
Presenting symptoms of choriocarcinoma
- Irregular vaginal bleeding
- Enlarged uterus
- pelvic pain
225
Choriocarcinoma is an aggressive type of gestational trophoblastic neoplasia. The most common site of metastases is where
lungs
226
What is commonly the sole presenting symptom of endometriosis
infertility
227
Pharyngitis with fever and lower abdominal pain in a young, sexually active patient is suggestive of what
-May present as pharyngeal edema and NONtender cervical lymphadenopathy
-Gonococcal pharyngitis with PID
228
Marijuana use while breastfeeding is condraindicated and has been associated with what effects on the baby
- decreased muscle tone
- poor suckling
- sedation
- Delayed motor development at age 1
229
What is the most accurate method of determining gestational age
First trimester US with crown-rump length
230
Newborn with: Large anterior fonatanel
- thin umbilical cord
- Loose, peeling skin
- Minimal subcutaneous fat
Fetal growth restriction
231
Evaluation of newborn with fetal growth restriction
- Placenta histopathology (usually due to utero-placental insufficiency)
- Consider karyotype, urine tox, serology
232
Neonatal complications in newborn with fetal growth restriction
- Polycythemia
- Hypoglycemia
- Hypocalcemia
- Poor thermoregulation
233
In fetal growth restriction, the placental histopatholgy is looking for what
Infarction and/or infection (e.g. spirochetes)
234
What are nonviable fetal diagnoses?
- Anencephaly
- Bilateral renal agenesis
- Holoprosencephaly
- Acardia
- Thanatophoric dwarfism
- INtrauterine fetal demise
235
Management of nonviable fetus
- Vaginal delivery
| - No fetal monitoring
236
US findings of ovary with Adnexal fullness on routine PE in otherwise asymptomatic patient that shows hyperechoic nodules and calcifications
Dermoid ovarian cyst (mature cystic teratoma)
237
What type of cysts have higher likelihood of ovarian torsion
Dermoid (mature cystic teratoma)
238
- Midfacial hypoplasia
- microcephaly
- cleft lip and palate
- digital hypoplasia
- hirsutism
- developmental delay
Fetal hydantoin syndrome
239
What features of fetal hydantoin syndrome are ABSENT in fetal alcohol syndrome
- Cleft palate
| - excess hair
240
Normal internal genitalia, external virilization (e.g. clitoromegly), and undetectable serum estrogen levels in a female patients are consistent with what Dx?
aromatase deficiency
241
Describe the findings in adolescents of patients with aromatase deficiency
- delayed puberty
- osteoporosis
- undetectable estrogen levels (e.g. no breast development)
- high concentrations of gonadotropins that results in polycystic ovaries
242
This is an X-linked abnormality characterized by hypogonadotropic hypogonadism with anosmia. Patients have delayed puberty but LH and FSH levels are low or absent
Kallman syndrome
243
this is marked by the triad of cafe au lait spots, polyostotic fibrous dysplasia, and autonomous endocrine hyperfunction
McCune-Albright syndrome
244
Most common endocrine features of McCune-Albright syndrome
Gonadotropin-independent precocious pubery
245
When can external cephalic version be performed
-between 37 weeks gestation and the onset of labor and has been shown to reduce the rate of C section
246
This is performed in twin delivery to convert the second twin from a transverse/oblique presentation to a breech presentation for subsequent delivery
Internal podalic version
247
Describe anovulation secondary to morbid obesity
- FSH and LH levels are normal
- Ovaries are still producing estrogen
- Progesterone is not being produced at the normal post ovulation levels
- Progesterone withdrawal menses at the end of the cycle does not occur
248
Thin, yellow green, malodorous, frothy discharge
| -Vaginal inflammation
Trichomoniasis
249
Thin, off-white discharge with fishy odor
| -NO inflammation
BV (Gardnerella vaginalis)
250
What are the indications for Cervical conization
-CIN grades 2 and 3
251
Complications from cervical conization
- Cervical stenosis
- Preterm birth
- PPROM
- Second trimester pregnancy loss
252
This refers to the formation of intrauterine adhesions from infection (e.g. severe endometritis) or intrauterine surgical interventions (e.g. Dilation and currettage, endometrial ablation, endometrial resection)
Asherman syndrome
253
If a patient has a history of CIN 2 or higher, describe the pap screening guidelines
-for another 20 years after detection and past 65 if indicated
254
A small vaginal pool of clear fluid seen on speculum examination can be due to urine or amniotic fluid. What makes SROM Less likely and Stress urinary incontinentce more likely?
- No fluid emerges from the cervix on valsalva
| - Nitrazine and fern tests are negative
255
Weight gain and OCPs?
-Although weight gain as a side effect is a common perception, several studies have shown no significant weight gain, particularly with low dose formulations
256
Copper IUD and dysmenorrhea?
Not recommeneded as its inflammatory reaction on the uterus may increase pain symptoms
257
Risks of combined OCPs
- VTE
- HTN
- Hepatic adenoma
- very rarely stroke and MI
258
during surgical removal of a mature dermoid cyst, intraperitoneal spillage of cyst contents should be avoided as it can cause what
chemical peritonitis
259
Which vaccines are CONTRAINDICATED during pregnancy
- HPV
- MMR
- Live attenuated influenza
- Varicella
260
- Dull and ill defined pelvic ache that worsens with standing
- Dyspareunia
Pelvic congestion
261
IN patients known to have SLE prior to conception, the appearance of proteinuria during pregnancy may represent an SLE flare complicated by nephritis, preeclampsia, or both. Distinguishing b/t lupus nephritis and preeclampsia can be difficult as both present with edema, HTN, and proteinuria. what additions signs point to SLE
- Joints pain
- Malar rash
- presence of RBC casts on UA
- decreased complement levels
- Increasing ANA
262
Infertility in 37 year old female with normal exam and normal menses
- Infertility can occur due to diminished ovarian reserve, characterized by decrease oocyte number and quality.
- Regular menstrual periods still occur due to continuing ovulation, but fecundability (conception rate) decreases due to diminished oocyte quality
263
Describe the etiology of low back pain during pregnancy
- Enlarged uterus --> exaggerated lordosis
- Joint/ligament laxity from Increased progesterone/relaxin
- Weak abdominal muscles --> decreased lumbar support
264
Imaging in low back pain during pregnancy
Not indicated
265
management of low back pain during pregnancy
- Behavioral modifications
- Heating pads
- Analgesics
266
Beta-hCG levels in a hydatidiform mole
>100,000
267
Clinical features of PMS
- Physical: Bloating, fatigue, HA, hot flashes, breast tenderness
- Behavioral: Anxiety, irritability, mood swings, decreased interest
268
Evaluation of PMS
symptoms/Menstrual diary over 2 mentrual cycles
| -Should demonstrate recurrence of symptoms during the luteal phase (1-2 weeks prior to menses)
269
Treatment of PMS
SSRI
270
what is the more severe variant of PMS
-PMDD (premenstrual dysphoric disorder)
271
This is an estrogen secreting ovarian tumor which leads to estrogenic symptoms like breast tenderness, postmenopausal bleeding, precocious puberty
Granulosa cell tumor
272
Describe the PE and imaging findings in Granulosa cell tumor
- Large pelvic/adnexal mass
- endometrial hyperplasia or carcinoma, which presents as postmenopausal bleeding and appears on US as a thickened endometrium
273
What situations make a medically emancipated minor?
- Emergency care
- STI
- Substance abuse (most states
- Pregnancy care (most states)
- Contraception
274
What are unsafe exercise activities in pregnancy
- Contact sports (e.g. BBall, hockey, soccer)
- High fall risk (e.g. downhill skiing, Gymnastics, horseback riding)
- Scuba diving
- hot yoga
275
fetal gastroschisis is associated with use of what in the first trimester
NSAIDs
276
All sexually active women age <25 are advised to undergo what annual gynecologic screening annually in addition to routine Pap testing
Chlamydia and Gonorrhoeae
277
Pathophysiology of type II osteogenesis imperecta
- Autosomal dominant
| - Type 1 collagen defect
278
US findings of type II osteogenesis imperfecta
- multiple fractures
- short femur
- hypoplastic thoracic cavity
- fetal growth restriction
- intrauterine demise
279
Prognosis of type II osteogenesis imperfecta
lethal
280
This is a non lethal autosomal dominant bone dysplasia that presents with macrocephaly, frontal bossing, midface hypoplasia, genu varum, and limb shortening
Achondroplasia
281
This is a lethal fetal anomaly that presents with pulmonary hypoplasia, limb deformities (e.g. clubfoot, hip dislocation), and oligohydramnios. The sequence is most commonly due to urinary tract abnormalities (e.g. bilateral renal agenesis, Polycystic kidney disease
Potter sequence
282
Describe the management of a patient who had suction curettage after a hydatidiform mole
- beta-hCG levels are followed weekly until undetectable
- A plateau or increase in the levels is diagnositc of gestational trophoblastic neoplasia (GTN)
- Once hCH is undetectable, monthly monitoring continues for 6 months, newly detectable level means GTN
- During the surveillance period, contraception is prescribed, as pregnancy would make it hard to determine the significance of a rising Beta-hCG level
- GTN rarely develops >6months after suciton curettage so after 6 months of undetectable levels, patients can attempt conception
283
What is first line treatment of gestational trophoblastic neoplasia
-methotrexate and hysterectomy
284
Describe the levonorgestrel containing IUD
- long acting, reversible, contraceptive
- releases a progestin, which creates a physical barrier by thickening cervical muus and impairing implantation through decidualization of the endometrium
- Common side effect is amenorrhea, which can be used to improve anemia and abnormal uterine bleeding
285
Copper IUD and heavy bleeding/anemia
-Can cause heavy menstrual bleeding and should not be placesin women with hypermenorrhea or anemia
286
Medroxyprogesterone injections and weight gain?
-weight gain is a common side effect
287
This typically presents with high fever, hypotension, and a diffuse red macular rash involving palms and soles
Toxic shock syndrome
288
This is a complication of PID and presents with fever, abdominal pain, and a complex multiloculated adnexal mass with thick walls and internal debris
Tubo-ovarian abscess
289
Lab findings in tubo-ovarian abscess
- increases in nonspecific indices (e.g. leukocytosis, CRP, CA-125)
- fever
290
- Female Precocious puberty
| - Large Adnexal mass
Granulosa cell tumor, a type of ovarian sex cord-stromal tumor
291
what hormones are elevated in Granulosa cell tumor
- Estradiol
| - Inhibin
292
Call-Exner Bodies (cells in rosette pattern) on histopathology
Granulosa cell tumor
293
Patients with Granulosa cell tumor before puberty present with what
- Early-onset breast development
- Vaginal bleeding due to endometrial proliferation
- Advanced bone age (> 2 standard deviations of chronologic age)
294
These are germ cell tumors that contain cells that differentiate into syncytiotrophoblast cells of the placenta. They can secrete lactate dehydrogenase or beta-hCG but they do NOT cause precocious puberty
Dysgerminomas
295
These are benign germ cell tumors composed of endodermal, mesodermal, and ectodermal tissue. They may secrete thyroid hormone (ie, struma ovarii)
Mature teratoma
296
These are ovarian sex cord-stromal tumors that produce androgens (eg, testosterone, androstenedione); patients with these tumors typically have virilization (eg, amenorrhea, deepening voice, cliorormegaly)
Sertoli-Leydig cell tumors
297
What are clinical features of a Granulosa cell tumor in Adulthood?
- Breast tenderness
- Abnormal uterine bleeding
- Postmenopausal bleeding
- Chronic unopposed estrogen can result in endometrial hyperplasia or cancer
